Melbourne/Mumbai: Sita Devi was in labour when her family paid the day’s first bribe. The wife of Shivvaran Pal, a subsistence farmer whom she’d married at 15, Sita worked on their land and earned a monthly wage of Rs.1,000, about $16, cooking school lunches. By 23, she had three daughters under age 3.
She shared a cluster of mud-and-dung huts with her in-laws in the north Indian village of Ukhdand, where Shivvaran tended buffalo and grew vegetables in rocky soil on the edge of the Vindhyachal hills.
When Sita went into labour with the couple’s fourth child on 8 January 2014, Paudhari, the community’s health aide, called an ambulance. As with most maternity services for women using state-run hospitals, the ride was supposed to be free. It wasn’t. The driver demanded Rs.150. Sita’s family appeased him with Rs.50, Bloomberg Markets magazine will report in its February issue.
All told, they would hand out at least Rs.750 on the final two days of Sita’s pregnancy, a sum it would have taken three weeks to earn at her cooking job.
The money Sita and millions of other Indian women pay buys them the worst maternal care in any major economy. Some 50,000 women in India died during childbirth and from pregnancy-related complications in 2013, according to estimates compiled by United Nations agencies.
That’s the most maternal deaths for any nation—17% of all such fatalities globally. For every 100,000 live births in India, 190 women die, ranking the country with Indonesia at the bottom of the Group of 20 nations.
Aid organization Save the Children puts India last in the G-20 in its Mothers’ Index, which measures pregnancy-related deaths; child mortality; and the economic, educational and political status of women. Out of 178 countries, India ranked 137th in 2014.
Although everyday bribery is rife throughout India, the petty fees extracted from poor women seeking maternity care are especially pernicious. The graft extends from hospital staff who demand money to change bandages to elected officials and top bureaucrats responsible for fixing up 134 hospitals in Sita’s state of Uttar Pradesh.
“Everyone up and down the rung of the hierarchy is engaged in corrupt practices,” says Jashodhara Dasgupta, who coordinates a reproductive-rights group called Sahayog. “Those lower down, even if they’re not poorly paid, feel it’s justified to also make a quick buck because everyone from the minister downward and the senior managers are trying to make money out of the patients, the health budget, the hospital fees. We have to see it as a very entrenched system that’s really depriving the poor of resources.”
India’s substandard maternal care perpetuates a cycle of poverty and disease that holds back families and stifles economic development, says K. Srinath Reddy, president of the New Delhi–based Public Health Foundation of India. The ill effects can last generations, he says. Unhealthy mothers give birth to small babies susceptible to diabetes, heart disease and other chronic illnesses in adulthood.
Sita was supposed to get at least four checkups to test her blood and urine for problems including anemia and gestational diabetes. She didn’t. For reasons no one can explain, the government clinic in her village had been shuttered for months, its windows boarded and tall grass growing behind the padlocked gate.
When Sita went into labour, the ambulance took her to the Parari Primary Health Centre, a pink building 17km away. Inside the dimly lit waiting room, women rest their heads on broken bricks before delivering side by side in the two-bed birthing room.
Sita had a difficult labour. The morning after she arrived at Parari, she was transferred by ambulance, this ride bribe-free, to the better-equipped Mirzapur District Women’s Hospital, about 20km away.
“We do not know what happened to her after she left here,” says Manjiri Singh, a nurse at the Parari clinic, who says the family left of their own volition.
At Mirzapur, in a ward with eight metal beds and blue buckets stationed nearby to catch bodily fluids, Sita’s baby emerged later that morning—a stillborn girl.
Sita was still bleeding from the delivery when Paudhari, the community health aide, asked Sita’s family for Rs.100 to augment the Rs.600 the government pays her for bringing pregnant women to public hospitals. She said she needed soap to wash Sita’s blood off her skin and to travel to her next appointment.
Sita’s mother-in-law, Man Kumari, who stayed with Sita throughout her labour, paid.
Paudhari says the small sums she and fellow community aides collect are more like tips than bribes.
“We don’t pressure anybody to give us money, but most people are happy to,” says Paudhari, who goes by that single name.
As Sita lay in a hospital bed, Shivvaran, 32, attended to the couple’s dead daughter. He and his nephew carried the infant about a kilometer to the Ganges, weighted a clay pot around her neck and cast her tiny body into the river.
When he returned, a doctor told him to get blood from the general hospital next door because Sita needed a transfusion. Shivvaran says the doors to the blood bank there were closed and he came back empty-handed. Before he could try the blood bank a second time, a nurse phoned to tell him not to bother. Sita had died.
“The doctor shook her foot a few times to see if she was alive,” Man Kumari recalls. Sita was 26 years old.
The family continued paying even after Sita’s death, Man Kumari says. She says a nurse told them Sita’s body would be taken away unless they removed it immediately. They agreed, and a nurse arranged for an auto-rickshaw to transport the dead woman to their village. The cost: Rs.600. If Sita had lived, she would have been entitled to a free ride home.
The fees charged to mothers are so pervasive that some women say they even have to bribe hospital staff to see their own newborns—about Rs.300 for a girl and Rs.500 for a boy.
If a mother resists, a hospital worker will say: “No problem; I’m not going to bring your baby back for you,” according to Kerry McBroom, director of the reproductive rights initiative at the New Delhi-based Human Rights Law Network.
Women interviewed and those who report their treatment to rights groups say they’re routinely asked for money for everything from bandages to blood.
Payments can start with aides such as Paudhari. She trained for 23 days to become an Accredited Social Health Activist, or ASHA. The government-sponsored programme lets her dispense basic drugs and advise rural women on contraception and breast-feeding.
“Usually, they give us money for transportation, for supplies—Rs.5 here and there,” she says. “It’s the minimum they should provide us for coming a long way.”
ASHAs can add Rs.150 to their incomes by convincing a woman to undergo sterilization, sometimes in appalling conditions.
At least a dozen women died and dozens more were hospitalized in November when a single doctor performed 83 sterilizations in six hours. One of the deceased was tricked by a midwife into getting the procedure, the woman’s husband told reporters. R.K. Gupta, the doctor who was arrested after performing the procedures, blamed the deaths on toxic medicine.
Incentives and bribes underpin a maternal-care system that’s overwhelmed by a birth every 1.2 seconds— 26 million babies in 2013.
Doctors don’t want to work in rural communities such as Sita’s, B.K. Tiwari, who was Mirzapur district’s chief medical officer at the time, said in August. He later became deputy chief. A first-year resident at Apollo Hospitals Enterprise Ltd’s flagship center in Chennai makes about $13,000 a year; the average starting salary for public hospitals in Mirzapur is $7,810.
Paudhari says hospital workers enlist ASHAs to help them pad their incomes by finagling money from families. She says the typical rate is Rs.500 for a normal delivery and Rs.1,000 for a cesarean section, which usually entails a longer stay.
“They’ll throw Rs.200 back in our face, telling us we’re not doing a good enough job convincing the families to pay,” she says.
Nurses can also be aggressive in extorting money from patients, women who have encountered the mistreatment say.
Bindu, an 18-year-old from a farming village south of Varanasi, hides her face behind the fabric of her multicolored sari as she recalls the birth of her first child at Mirzapur District Women’s Hospital, where Sita died.
The nurse covered her mouth and hit her leg when she cried during labor, she says. After the baby was born, the nurse asked for Rs.100 for drugs and Rs.500 because Bindu had had a son. Bindu’s husband, Sunil, explained they could afford just Rs.300. The nurse berated him for not paying the asking price.
“She said, ‘I’ll remember you the next time you come to the hospital,’” Sunil recalls. “‘If there’s a complication and she needs surgery, you’ll need to pay more.’”
Rita Bhaskar is one of seven women lying on stained maroon sheets at Mirzapur District Women’s Hospital on a sweltering August day. Two ceiling fans do little to ease the heat as a rat skirts the room. Bhaskar, 23, says nurses demanded Rs.1,500 for her C-section and ask for Rs.100 every time they change her bandages. She says she knows the fees are wrong, but her in-laws are afraid she’ll be neglected if they don’t pay.
Shashi Mishra, Mirzapur District Women’s Hospital’s chief medical supervisor, says she doesn’t want to discuss bribes or the 45 childbirth-related deaths the hospital reported in the 12 months ended on 31 March. She declined to talk about Sita’s case, citing patient privacy. Mishra says she oversees as many as 60 births on busy days and performed 11 C-sections herself the day before the interview.
“Why do you want to tell people in other countries what is happening here?” she asks. “Do you want to put us to shame? Our bureaucrats are thick-skinned. What you write will make no difference in the way things work.”
Since Prime Minister Narendra Modi swept into office in May, his administration has earmarked about Rs.300 crore to test a project that would increase women’s safety on public transportation and establish crisis centers for female victims of violence in New Delhi hospitals, among other initiatives.
“Maternal care is a priority,” says Harsh Vardhan, who, until November, was India’s health minister. “It’s an area for absolute, thorough, specialized attention for us,” he said in an interview in September.
Vardhan said most healthcare workers are honest.
“All these small things that take place somewhere here and there, what you call corruption, they are aberrations,” he said. “We are strengthening monitoring mechanisms. We have said we are not going to tolerate either corruption or inefficiency.”
The office of J.P. Nadda, Vardhan’s successor, didn’t respond to emailed and faxed questions about how the government would stop women from dying in childbirth.
Modi sought to safeguard motherhood in 2005 when he was chief minister of Gujarat. He wanted to curb home births that typically lack skilled attendants and emergency equipment. At that time, about half of India’s babies were born at home because few people had health insurance and hospitals could be prohibitively expensive: Citizens paid on average 70% of health expenses out of their pockets.
The Gujarat government offered pregnant women free hospital care. To handle the demand, the state paid private hospitals Rs.1,600 for each delivery. The plan flopped, a study in the Bulletin of the World Health Organization found in 2013.
The chance of dying in childbirth wasn’t reduced nor was the money families paid, probably because of informal fees, says research leader Manoj Mohanan, an assistant professor of public policy at Duke University in Durham, North Carolina. Gujarat’s health minister didn’t respond to a call and an e-mail seeking comment.
The same year Modi unveiled his effort, then-Prime Minister Manmohan Singh launched an ambitious countrywide strategy. The National Rural Health Mission, now called the National Health Mission, provided about $15 billion to protect mothers and babies, curb births and build health centers, among other aims.
In 2011, Sonia Gandhi, then-chairperson of the ruling United Progressive Alliance (UPA), announced a plan by Singh’s government making maternity and neonatal services free in all public facilities. ASHAs encouraged women who might otherwise deliver at home to choose a hospital instead.
One mission centerpiece called Janani Suraksha Yojana was riddled with petty bribery. The programme, whose name means plan to protect mothers, promised women as much as Rs.1,400 if they gave birth in a public hospital. The effort increased hospital deliveries but wound up costing in illicit fees.
A survey of 410 new mothers in Uttar Pradesh found they spent an average Rs.1,277 to get the promised Rs.1,400 stipend.
“If we had good-quality services, women wouldn’t need incentives,” says Poonam Muttreja, executive director of the New Delhi–based Population Foundation of India. “The demand is greater than the supply. We have inefficient systems; we have corruption.”
Anuradha Gupta, the Health Mission’s director from January 2012 to June 2014, says India is making progress. During Gupta’s time at the helm, 470 hospital wings for mothers and children were constructed, adding 30,000 beds.
Today, 74% of babies are born in a hospital or clinic, compared with 47% in 2005, says Gupta, now the deputy chief executive officer of Geneva-based Gavi, which increases access to vaccines. Gupta says Uttar Pradesh, India’s most populous state, with 200 million people, is an exception to the positive momentum.
“At the bottom of the pile, you have Uttar Pradesh,” she says. “It is not representative of India.”
Uttar Pradesh is the site of a massive investigation into missing and misspent mission funds.
The Central Bureau of Investigation (CBI) is looking into 73 transactions involving doctors, officials and suppliers totaling Rs.8,660 crore, says Kanchan Prasad, a spokeswoman for the federal agency.
Officials overpaid for everything from iron-folate tablets to TVs to earn kickbacks from suppliers, government auditors say. The state health department paid Rs.100 crore for 1,293 laparoscopes for keyhole sterilizations, like those used in the November deaths—almost triple the number of doctors trained to use them.
Authorities ordered almost 600 ambulances and left them to rust; a further 190 never arrived. Twenty-one new clinics weren’t in use in 2011, a year after their construction; others were storing rice, carrots and potatoes. Six other states uncovered similar irregularities with their mission funds.
The CBI has arrested 54 people. The Uttar Pradesh ministers for both health and family welfare resigned, taking “moral responsibility” for irregularities in implementing the mission plan, according to a November 2011 judgment by the high court of judicature at Allahabad.
Some women are going public with the financial malfeasance. A project called My Health, My Voice encourages them to use mobile phones to report maternal deaths and demands for illegal payments for supplies, exams, hospital admissions, blood or surgery. Families made 1,096 calls from January through September 2014. One hospital in Atraulia, about 160km north of Mirzapur, was named in 55 complaints.
“India’s healthcare is marred by both megacorruption and the petty corruption that results in patients having to pay bribes to get basic services,” says Ashutosh Kumar Mishra, executive director of Transparency International’s India chapter. “Corruption damages not only the health of women, but it also damages the image and health of the nation.”
Six months after Sita’s death, Man Kumari sits outside the dun-colored home she shared with her daughter-in-law, recounting the course of a pregnancy that took the family from hope to horror.
When Sita announced she was expecting, everyone prayed for a boy.
“Who doesn’t want to have a son?” Man Kumari says, echoing a common thought in rural India, where boys are viewed as more likely to boost prosperity.
Paudhari, the community aide, saw signs the family might get their wish.
“She was big and strong, so we all thought she’d have a son,” she says.
The assessment was speculation. Sita never got the care the National Health Mission specified. The yellow card the government provided to track her pregnancy shows no entries for blood pressure, pulse, anemia, and abdominal and fetal exams. Sita was too busy to get her card filled out, Paudhari says.
Man Kumari recalls Sita’s final hours. She says a nurse determined Sita hadn’t expelled the placenta and tugged it out.
“The nurse yelled at her to make her stop screaming, ‘If you keep screaming, all the filth will stay inside you and rot,’” Man Kumari says the nurse warned.
When Man Kumari covered Sita with a blanket, the bed was drenched with blood.
“Their neglect killed her—the irresponsibility of the hospital,” she says.
Sita died of severe anemia with heart and respiratory failure, records from medical officer Tiwari show. The cause of the stillbirth is unknown. Neither the clinic where Sita was first admitted nor the hospital where she died ran a hemoglobin test, so nobody anticipated the hemorrhage risk.
Because he was unable to obtain blood with the blood bank’s doors closed, Shivvaran will never know if a transfusion might have saved Sita—and whether getting the blood would have required another bribe.
Shivvaran remarried in June. His new bride hides during a visit in July, her face and upper body veiled by her pink sari.
“What to do?” says Man Kumari, tousling the hair of Sita’s youngest daughter, Nisha, who’s about 3. Sita’s other girls, Vandana, 5, and Manisha, 4, play outside.
“Marriage is necessary,” Man Kumari says. “We found a decent girl, so we had to do it.”
At the Parari clinic where Sita laboured all night, the moist air smells of blood and sweat on an August afternoon. A woman lies on the floor. When it’s her turn, she’s helped onto the bare metal bed. After 20 minutes of pushing, she delivers her first son after three girls. People admire his light skin before the bed is wiped for the next delivery. Latex gloves dry on a rail, inches from the ground.
When asked why there’s no physician on duty, Tiwari says there should be. But doctors don’t want to work around Mirzapur, he says.
“Everybody,” he says, “wants something better for themselves.” Bloomberg